What's New with HCFO - April 13, 2007 (Print All Articles)
SCHIP Reauthorization – Expand, Reduce, or Maintain?
The 110th Congress marks the beginning of the first reauthorization for the State Children’s Health Insurance Plan (SCHIP). As the debate begins, primary issues up for discussion involve appropriate funding levels and the choice of some states to use waivers to expand coverage to slightly higher income groups, parents, and childless low-income adults.
SCHIP, established by the 1997 Balanced Budget Act, covers 6 million low-income children who do not qualify for Medicaid but fall below specified income thresholds. Specifically, 24 states set their income threshold at 200 percent of the Federal Poverty Level (FPL), 10 states are set below 200 percent FPL, and 17 states are set above 200 percent FPL.1 Twelve states have waivers to expand coverage to parents and six states have waivers to cover some childless adults.2
Due to the maturation of state programs, economic downturns, and increasing healthcare costs, FY2007 marks the first year that a significant portion of states (17) will face a budget shortfall. In some states, budget constraints have led to enrollment freezes, waiting lists, lowering income eligibility, decreasing outreach efforts, and various enrollment barriers.3
The President’s FY2008 budget proposes $4.8 billion annually over five years. It also would limit coverage of new enrollees to children and decrease federal matching rates for enrollees who are above 200 percent FPL.4 Critics argue that this proposal would eliminate insurance coverage for more than one million persons over the next four years.5
Reports from the Congressional Research Service estimate that to maintain coverage for the current level of enrollees would require an additional $12.1 billion above and beyond the program’s current FY2007 baseline funding level of $5 billion per year.6
Several financing options have been proposed, but federal budget rules require that additional funding be offset elsewhere in the federal budget. Some proposals being considered include readjusting reimbursement to Medicare Advantage plans and increasing the federal cigarette tax.7 Congress is simultaneously working to address FY2008’s budget and the SCHIP shortfalls faced in FY2007.
Some view the reauthorization process as an opportunity for expansion. This may include more aggressive strategies to cover the 2 million eligible but uninsured children, encompassing low-income parents, including currently excluded groups of low-income children, and providing wrap-around benefits to private insurance covering low-income children. Some have even advocated the use of SCHIP as a vehicle for achieving universal insurance. The argument for expansion is based on research showing that SCHIP has had a positive impact on improving access to care and preventative services, meeting unmet needs, and reducing hospital admissions.8
Linda Blumberg, Ph.D. and Lisa Dubay, Ph.D. of the Urban Institute looked at the effect of SCHIP enrollment over time in their HCFO-funded project. Their findings, detailed in the June 2006 HCFO Findings Brief, indicate that over the study period, SCHIP decreased uninsurance among the target population and did not lead to significant “crowd-out,” the substitution of public coverage for private.9 Another HCFO grantee, Ted Joyce, Ph.D. of the Research Foundation of CUNY, found that SCHIP may not have a significant impact on all areas of child health care needs. Joyce examined the effect of SCHIP implementation on immunization rates. He found that while insurance coverage may be necessary, SCHIP had little impact on narrowing the gap of immunization rates between low-income children and non-poor children.10
Despite outreach efforts, 9 million children are still uninsured, the majority of whom are eligible for either Medicaid or SCHIP.11 HCFO grantee Chyongchiou Lin, Ph.D. of University of Pittsburgh, examined possible factors that may be impeding enrollment of eligible children into SCHIP and Medicaid. Lin identified welfare and citizenship documentation reforms in addition to language barriers as factors related to whether eligible children were in enrolled in either program. She recommends that the enrollment process and outreach activities be culturally and linguistically sensitive to non-English speaking populations.12
As the reauthorization process begins, there will be multiple opportunities for research-based evidence to contribute to the debate about funding levels and distribution, program participation, retention, benefits, and quality.
Related HCFO Funded Research
Title: The Dynamics of Health Insurance Coverage: 1996 to 2000
Institution: The Urban Institute
Principal Investigator: Linda Blumberg, Ph.D.
Grant Duration: September 2003 - October 2005
What are the effects of certain insurance market reforms that were designed to expand coverage? Researchers at the Urban Institute examined the dynamics of health insurance for children and adults under age 65 from 1996 to 2000, a dynamic period characterized by the implementation of national welfare reform, SCHIP, and an economic boom. They documented the patterns of insurance coverage and public program eligibility, estimating the impact of the implementation of SCHIP on insurance coverage for eligible children and previously Medicaid eligible children, and assessing the extent to which the economic expansion affected the insurance coverage of previously uninsured adults. The objective of this project was to inform the design of more effective strategies to maintain or increase insurance coverage and to understand better the determinants of participation and crowd-out that can be useful when considering coverage expansions. The findings will also help to better predict the implications of reductions in coverage resulting from states’ efforts to balance their budgets or in the economic context of a recession.
Title: The Effect of the State Children’s Health Insurance Program on Immunization Rates: Evidence from the National Immunization Survey
Institution: Research Foundation of CUNY
Principal Investigator: Ted Joyce, Ph.D.
Grant Duration: January 2003 - June 2004
What is the effect of the State Children’s Health Insurance Program (SCHIP) on children’s immunization rates? Specifically, what is the likelihood that low-income children, after the implementation of SCHIP, are up to date on vaccinations, receive their immunizations on time, and receive vaccinations from a provider that offers comprehensive pediatric services (instead of a vaccine-only public health setting)? The researchers compared immunization coverage rates and the sites where the vaccines were received before SCHIP was implemented with those after implementation in all 50 states. The results for low-income children were compared to a control group of non-low-income households. This project evaluated the effectiveness of SCHIP in accomplishing the specific objective of increasing immunization among low-income children.
Title: Factors Associated With Health Insurance Coverage for Low-Income Children
Institution: University of Pittsburgh
Principal Investigator: Chyongchiou Jeng Lin, Ph.D.
Grant Duration: March 1999 - July 2000
What factors impede enrollment into Medicaid by children who are eligible based on their family’s income level? Using data from the Community Tracking Study Household Survey, state Medicaid and CHIP eligibility data and the Area Resource File, researchers at the University of Pittsburgh tested two hypotheses: 1) that the decision to enroll a child is a function of family, child, and other characteristics; and 2) the more widespread poverty is in a community the less likely a child is to be enrolled by the family into Medicaid. The analyses also explored the interaction between utilization of health care services and propensity to enroll in Medicaid. This study had the following three objectives in mind: 1) to identify the factors that influence enrollment of Medicaid-eligible children into the program that will inform policy recommendations to help increase enrollment of children, 2) to develop baseline data on children who would presumably be eligible for the Children’s Health Insurance Program (CHIP); and 3) to describe the utilization of health services by children.
1 Kaiser Commission on Medicaid and the Uninsured. “State Children’s Health Insurance Program (SCHIP) at a Glance,” Kaiser Family Foundation, January 2007.
2 Kaiser Commission on Medicaid and the Uninsured. “A Decade of SCHIP Experience and Issues for Reauthorization,” Kaiser Family Foundation, January 2007.
3 Ibid.
4 Kaiser Daily Health Policy Report. “Democrats Focus on President Bush’s SCHIP Funding, Eligibility Proposals,” Kaiser Family Foundation, February 7, 2007.
5 Center for Children and Families, “SCHIP’s Financing Structure,” Georgetown University Health Policy Institute, October 2006
6 Peterson, C. “SCHIP Financing: Funding Projections and State Redistribution Issues,” Congressional Research Service, Order Code RL32807, Updated January 30, 2007.
7 Kaiser Daily Health Policy Report. “HHS Secretary Leavitt Says Administration Opposes Reducing Medicare Advantage Payments to Shift Funds to SCHIP,” Kaiser Family Foundation, March 23, 2007.
8 Kenney, G. and J. Yee. “SCHIP at a Crossroads: Experience to Date and Challenges Ahead,” Health Affairs, March/April 2007, Vol. 26, No. 2, pp. 356-369.
9 Brodt, A. “The Dynamics of Health Insurance Coverage: 1996 to 2000,” HCFO Findings Brief, Vol. 9, No. 3, June 2006.
10 Joyce, T. and A. Racine. “CHIP Shots: Association Between the State Children's Health Insurance Programs and Immunization Rates,” Pediatrics, May 2005, Vol. 115, No. 5, pp. 526-534.
11 Urban Institute analysis of the 2005 Annual and Social Economic Supplements to the CPS for Kaiser Commission on Medicaid and the Uninsured. Presented by Diane Rowland on February 9, 2007.
12 Lin, C.J., et al. “Factors Associated with Medicaid Enrollment for Low-Income Children in the United States,” Journal of Health and Social Policy, March 2003, Vol. 16, No. 3, pp. 35-51.
Grantee Spotlight - Steven Pizer, Ph.D.
Steven Pizer currently holds a joint appointment as an Assistant Professor of Health Policy and Management with the Boston University School of Public Health and a Health Economist with the Department of Veterans Affairs. Before joining BU and the VA, Pizer served as a health economist for Abt Associates, Inc. Prior to receiving his Ph.D. in 1998 from Boston College, Pizer directed a Massachusetts consumer organization and worked for the human services committee of the Massachusetts Legislature. His research interests include the economics of health insurance, long-term care financing and quality regulation, health econometrics, and policy development and analysis using microsimulation models.
In 2004, Pizer took the lead on a HCFO sponsored project which originally planned to investigate the prospects for stability and sustainability of the competitive bidding structure for Medicare private health insurance plans. With the passage of the Medicare Modernization Act (MMA) in late 2003, the proposed analyses were adjusted to include the new prescription drug plans (PDPs), and regional Preferred Provider Organizations (PPOs). With Austin B. Frakt, Ph.D. (VA and BU), and Roger Feldman, Ph.D. (University of Minnesota), Pizer explored the impact of adverse selection in PDPs, the entrance of PPOs into regional markets where health maintenance organizations (HMOs) already exist, and the introduction of PDPs and PPOs in markets where HMOs did not have a presence.
The researchers concluded that in general, PDPs will be stable, regardless of adverse selection, and that premium support of these programs will ensure viability. Pizer notes that “huge numbers of people now rely on these plans for drug coverage, this study indicates that the most popular Medicare drug plans will be stable and reliable as long as Congress maintains the premium subsidies.” Their research also found that regional PPOs would be unlikely to attract large and stable enrollments without very costly ongoing subsidies from the Medicare program. Simulation models estimated that regional PPO enrollment would cost approximately $1,600 in subsidy above fee-for-service cost per enrollee, or over $6 billion to enroll fewer than 4 million beneficiaries for one year.
For more information on his HCFO work, please visit the HCFO Grants Web site.
For a list of selected projects and publications, please visit Steven Pizer’s VA Web site or BU Web site.
New HCFO Grant Announced
Grant No.: 60517
Title: Evaluating Cost Efficiency of Specialist Physicians
Institution: University of Southern Maine
Principal Investigator: J. William Thomas, Ph.D.
Grant Duration: April 2007 - March 2009
Paragraph Summary: The researchers will analyze alternative strategies for measuring specialist physician cost efficiency. Accurate measures of physician cost efficiency allow consumers to make more informed decisions, while helping health plans make better choices about which physicians to include in their networks. Specifically, the researchers will explore the: (1) feasibility of using multi-plan claims databases for cost efficiency measurement; (2) need for risk adjusting episode expected costs to account for patients' comorbidities; (3) methodology for dealing with cost outlier episodes; (4) methodology for attributing responsibility for individual episodes to individual physicians; (5) minimum episode sample sizes required for cost efficiency measurement; (6) methodology for case-mix standardization; (7) influence and availability of pharmaceutical claims on cost efficiency measurement; and (8) suitability of ratio of observed to expected cost as a cost efficiency metric. The objective of the study is to develop standard methods for measuring the cost efficiency of specialist physicians, providing a broad range of stakeholders with reliable means for developing physician networks, assigning tiers, and implementing better public reporting.
Spotlight on Grantee Publication
Mark Edlund, M.D., Ph.D., assistant professor of Psychiatry at the University of Arkansas for Medical Sciences, and Thomas Belin, Ph.D., professor of Biostatistics at the UCLA School of Public Health, co-authored an article titled, “Geographic Variation in Alcohol, Drug, and Mental Health Services Utilization: What are the Sources of the Variation?” that appeared in the September 2006 issue of the Journal of Mental Health Policy and Economics. The article describes HCFO-sponsored research examining the extent to which geographic variation in assessment and treatment rates for alcohol, drug, and mental disorders (ADM) was due to variation in case-mix across sites and quantifies the amount of geographic variation after case-mix adjustment.
Current HCFO grantee publications and recent grant findings will be regularly featured in the results section of our Web site.
New HCFO Findings Brief
“Investment Returns and Size of Damage Caps Impact Rising Cost of Malpractice Premiums”
While the call for federal medical malpractice reforms has cooled with the change in leadership in the Congress, the American Medical Association and nine other physician organizations continue to identify tort reform as a key element in reforming the U.S. health care system. A number of laws have been introduced that attempt to stabilize premium prices, damage caps being the most well-known, but their effectiveness has been unclear. Researchers at the Lister Hill Center for Health Policy, University of Alabama at Birmingham conducted a rigorous analysis of more current data to help eliminate some of the confusion created by the conflicting findings of past studies.
The research team, led by Michael Morrisey, Ph.D., Meredith Kilgore, R.N., MSPH, Ph.D., and Leonard Nelson, J.D., L.L.M. found that damage caps do have an impact on premium growth, though other tort reforms have either minimal or no effect. In fact, they found that the impact caps have on premium growth is related to the size of the cap. Damage caps set at $250,000 or less in 2004 dollars were estimated to reduce internal medicine premiums by 25%, caps of $250,000 to $500,000 reduced premiums by 11.5% but caps of $500,000 to $750,000 increased premiums by an estimated 7.9%. Caps above $750,000 increased premiums even more. They also determined that investment returns do play a role in the cost of premiums.
Morrisey and his colleagues argue that this study is important so that, “as the states and perhaps Congress debate legislation, they will have a rigorous analysis of the current environment to identify the effects that may result from changes in the law.”
This Month in the News
Judith Hibbard, Dr.P.H., professor of public health at the University of Oregon, was quoted in a March 19, 2007 article in the Philadelphia Inquirer that examined the growing number of people turning to the internet for health information. The article notes that a Pew Internet & American Life Project survey found that 113 million people searched the internet for health information in 2006. Hibbard states that "plenty of quality information is being produced and disseminated, but it has been an uphill battle making it really understandable and salient for consumers.”
Mila Kofman, J.D., associate research professor at Georgetown University’s Health policy Institute, was quoted in a March 27, 2007 article in the Los Angeles Times that explored the decline in health insurance offerings by professional associations. The article notes that many associations stopped offering coverage when younger, healthier members were able to purchase coverage on their own at lower cost. Kofman states, “if you can get cheaper coverage through the individual market, that’s what you do.”
James Verdier, Ph.D., an analyst at Mathematica Policy Research, was featured in a March 2007 article in The Commonwealth Fund Digest that highlighted Verdier’s evaluation of the DirigoChoice health plan in Maine. Verdier's ongoing study is jointly funded by HCFO and The Commonwealth Fund.
The Sixth Public Health Systems Research Meeting: Building an Evidence Base for the Public Health System
Preliminary Agenda
7:00 a.m. Registration
12:00 p.m. PHSR Poster Program & Box Lunch
12:45 p.m. Welcome
1:00 p.m. Call for Panels Session: Preparing the Public Health Infrastructure
2:00 p.m. Call for Panels Session: Models of Public Health Promotion & Partnership
3:00 p.m. Break
3:30 p.m. PHSR: New Role for CDC
> Recommitment to PHSR within Office of Chief of Public Health Practice
> Selected PHSR Research for 2007 OCPHP Funding
> Additional Funding Opportunities
3:50 p.m. Call for Panels Session: New Strategies for Public Health Assessment
& Data Systems
5:00 p.m. PHSR Town Hall Meeting & Hot Topics Session
> Establishing the Public Health Accreditation Board
> Late-Breaking Topics in PHSR
> Advancing the PHSR Research Agenda
5:30 p.m. PHSR Interest Group Announcements & Updates
5:45 p.m. 2006 PHSR Article of the Year Award Presentation
and Student Scholarship Announcement
6:00-7:00 p.m. Reception: Featuring Article of the Year and Student Posters
This meeting is sponsored by Robert Wood Johnson Foundation.
You do not need to register for the ARM to attend this meeting. Please visit the PHSR IG webpage for more information.
Building Bridges: Making a Difference in Long-Term Care 2007 Colloquium
Saturday, June 2
Workgroup Breakfast
7:15 am - 8:00 am
Building Bridges: Making a Difference in Long-Term Care
2006 Colloquium
8:00 am - 4:00 pm
Join us for the fourth annual LTC Colloquium, sponsored by The Commonwealth Fund and conducted by AcademyHealth.
David Grabowski of Harvard Medical School will present highlights from a commissioned paper on Medicare and Medicaid: Conflicting Incentives for Long-Term Care, followed by commentary from a panel of experts including: Diane Archer of Medicare Rights Center and William Weissert of Florida State University, as well as table discussions among participants.
The afternoon session will debut a forum discussion on an important issue with a minimal evidence base – Consumer Preparedness for Long-Term Care. Panelists will address the alarming discrepancy between consumers' expectations with respect to long-term care and their actual needs. Len Fishman of Hebrew SeniorLife will facilitate a discussion among: Lisa Alicxih, The Lewin Group; Brian Burwell, Thomson Medstat; Robert Kane, University of Minnesota; and Brenda Spillman, Urban Institute.
* ARM registration is not required to attend the Colloquium.
LTC Interest Group Next Generations Reception
4:00 p.m. - 5:30 p.m.
Sunday, June 3
LTC Interest Group Business Meeting
7:30 a.m. - 8:30 a.m.
The 2007 ARM also features LTC sessions Sunday through Tuesday. View the ARM Web site for more information.
Full Agenda Available for the 2007 Annual Research Meeting (ARM)
June 3-5 * Walt Disney World Swan and Dolphin *
Online registration closes April 30. View the full agenda and register today.
The 2007 ARM covers a wide range of policy and practice relevant health services research in more than 140 breakout sessions and over 800 poster sessions. This year’s meeting will offer sessions related to health care markets and financing that range from tracking health system change to the affects of market structure on access to care and quality. Along with cutting edge research, top-notch speakers, and leading experts, this year’s meeting provides:
* Policy roundtable debates on pressing health care issues facing decision makers;
* Skill building methods workshops;
* Interest group meetings;
* Career training; and
* Networking opportunities.
Hone Your Skills with Methods Seminars
Attend pre- and post-conference seminars in health services research methods to learn about hierarchical modeling, Bayesian methods, endogenous explanatory variables, and HCUP and NHANES data. Additional registration required.
Explore Your Area of Focus at the Interest Group and Adjunct Meetings
Interest Groups provide a forum for members to share information, network with their peers, and learn more about a topic. Enhance your meeting experience by attending AcademyHealth's Interest Group meetings and participating in discussions on topics of interest to you. Additional registration required.
The fourth annual Long-Term Care Colloquium, sponsored by The Commonwealth Fund and conducted by AcademyHealth, will provide an opportunity for long-term care (LTC) stakeholders to forge an agenda and bring information to bear on a set of problems faced by LTC policymakers and practitioners. This meeting will highlight two new long-term care issues: Medicare and Medicaid: Conflicting Incentives for Long-Term Care; and Consumer Preparedness for Long-Term Care.
New NCHS Report on Office-based Medical Practices
The National Center for Health Statistics (NCHS) is pleased to announce the release of a new report, entitled “Office-based Medical Practices: Methods and Estimates from the National Ambulatory Medical Care Survey”. The report provides descriptive statistics about office-based medical practices in 2003-04, and explains the methods by which researchers may weight data from individual physicians to produce estimates about medical practices. Report highlights include the observation that two-thirds of all medical practices consist of solo practitioners, but only one-third of office-based physicians practice by themselves. Similarly, the one-fifth of office practices having three or more physicians contains more than one-half of all office-based physicians. For decisions that are made at the practice level, these distinctions are important. For example, in 2003-04, 19 percent of physicians used electronic medical records, but only 15 percent of medical practices used them. The report may be accessed at: http://www.cdc.gov/nchs/data/ad/ad383.pdf.
The data upon which this report is based are available to the public as part of the National Ambulatory Medical Care Survey (NAMCS). NAMCS collects data from a national probability sample of office-based physicians. Data are collected about the physicians, their patients, and the services they deliver. The sample excludes federally employed physicians, those who specialize in anesthesiology, radiology, or pathology, and physicians who do not see patients in an office. NAMCS public use data files are available for the years 1973-1981, 1985, and 1989-2004 at: http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm#Micro-data.
NAMCS is part of a larger group of surveys known collectively as the National Health Care Surveys. Each survey collects data on health care providers and provider organizations, the patients they serve, and the services delivered. For information on surveys of long term care, inpatient care, and ambulatory surgery, please visit www.cdc.gov/nchs/nhcs.htm.
CMS announces Medicare Current Beneficiary Survey 2005 data file
The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey conducted by the Centers for Medicare & Medicaid Services (CMS). The MCBS sample of 16,000 represents the national Medicare population. The central goals of MCBS are to determine expenditures and sources of payment for all services used by Medicare beneficiaries, including co-payments, deductibles, and noncovered services; to ascertain all types of health insurance coverage and relate coverage to sources of payment; and to trace processes over time, such as changes in health status, spending down to Medicaid eligibility, and the impacts of program changes.
The newly released 2005 Access to Care file contains summaries of use and expenditures for the calendar year from Medicare files, along with survey data on insurance coverage, health status and functioning, preventive services, medical conditions, access to care, Medicare knowledge and access to information, satisfaction with care, living arrangements, and income. Cross-sectional and longitudinal weights are included, as well as variables needed to calculate standard errors. This release will be followed in late 2007 by an additional file that includes reconciled medical event, charge, and payment information.
The file can be obtained through a Data Use Agreement with CMS. Further information is available from the MCBS web site, http://www.cms.hhs.gov/mcbs -- or by calling William Long at (410) 786-2927.